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Dual Diagnosis: Bulimia And Addiction

Dr. Alan Weiner MD

Medically reviewed by

Dr. Alan Weiner, MD

February 11, 2019

Bulimia has a wide-array of side effects and dangers, the most serious of which can be death. Many of these can also be caused independently by substance abuse.

Many times, a person that struggles with a substance abuse disorder may also suffer from another condition, or comorbid disorder, in addition to their drug or alcohol problem. Eating disorders, including bulimia nervosa, maybe one of these. Though it may be hard to determine which one occurred first, both must be treated with appropriate and specialized care in order to fully ensure that the individual has the best chance of recovery and optimal health.

What Is Bulimia?

Occasionally worrying about your weight is normal, but when this worry becomes compulsive and you develop an unhealthy relationship with your food and the practices that surround it, then it becomes an issue. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) “bulimia nervosa is characterized by frequent episodes of binge eating followed by inappropriate behaviors such as self-induced vomiting to avoid weight gain.”

It is worth mentioning, that in this newest edition of the DSM, the frequency of “binge eating and compensatory behaviors” required for this diagnosis has been reduced from two times per week to one.

Bulimia nervosa can affect anyone, but as reports, a startling 85-90% of those that suffer from it are women. Though scientists continue to research and study bulimia, the site does go on to outline the following factors that may play into a person’s susceptibility of developing this eating disorder:

  • Culture. Women in the U.S. are under constant pressure to fit a certain ideal of beauty. Seeing images of flawless and thin females everywhere often makes it hard for women to feel good about their bodies.
  • Families. If you have a mother or sister with bulimia, you are more likely to also have bulimia. Parents who think looks are important, diet themselves or criticize their children’s bodies are more likely to have a child with bulimia.
  • Life changes or stressful events. Traumatic events (like rape), as well as stress (like starting a new job), can lead to bulimia.
  • Personality traits. A person with bulimia may not like herself, hate the way she looks, or feel hopeless. She may be very moody, have problems expressing anger, or have a hard time controlling impulsive behaviors.
  • Biology. Genes, hormones, and chemicals in the brain may be factors in developing bulimia

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What Are The Symptoms?

It is important to remember that unlike other eating disorders, such as anorexia, a person that suffers from bulimia may outwardly maintain what appears to be a normal weight. Due to this, it is important to be attentive to other signs and symptoms that may signify the presence of this eating disorder:

  • The constant fear of gaining weight
  • An abnormal or excessive worry about body weight, shape, or size
  • Struggling to control your eating habits
  • Hoarding food, eating in secret, or being embarrassed to eat around others
  • Imposing strict caloric restrictions on yourself or forbidding yourself to eat certain foods
  • Consuming more food than is typical or necessary during a meal or snack (binging), oftentimes to the point of experiencing pain or discomfort
  • After binging, making yourself vomit or exercise in excess to prevent weight gain
  • Going to the restroom immediately the following eating to purge or vomit
  • Sores, redness, or callouses on the hand or fingers (specifically on the knuckles) which may be indicative of a purging habit
  • Using herbs, supplements, or diet pills that promise weight loss
  • Inappropriately using a diuretic, laxative, or enema after you’ve eaten to moderate the effects of your food intake and outtake
  • Deterioration of teeth or gums

If you or someone you love exhibits these signs, seek medical help immediately. This is a serious medical condition and, if left untreated, can cause serious complications and dangers to your health.

The Dangers of Bulimia Echo Those of Substance Abuse

Bulimia has a wide array of side effects and dangers, the most serious of which can be death. Many of these can also be caused independently by substance abuse. Here, we list the most common side effects and risks of bulimia:

  • Heart issues, including heart irregularities, or in worst cases—heart failure: Most substance abuse causes significant damage to the heart. The National Institute on Alcohol Abuse and Alcoholism report that drinking heavily can cause “cardiomyopathy – stretching and drooping of the heart muscle, arrhythmias – irregular heartbeat, stroke, and high blood pressure.”

The American Heart Association specifically cites that cocaine, amphetamine, and ecstasy can all create cardiovascular risks. In addition, opioid drugs, PCP, and inhalants all present a risk for heart damage.

  • Dental problems, including tooth decay and gum disease: Individuals that abuse drugs or alcohol may be apt to make poor dietary choices and consume foods or beverages high in sugar (opiates can oftentimes cause a person to crave sugary foods). Some drugs, including stimulants and marijuana, may cause dry mouth, which may then lead a person to consume large quantities of sugar-laden drinks or alcohol. Sugar is far more destructive in a dry mouth that is devoid of the protection that salvia offers. A person suffering from substance abuse may also be apt to forget about personal grooming habits—such as brushing their teeth—this can, in combination with the aforementioned behaviors, put a person at greater risk for developing dental problems.

Certain drugs can themselves cause dental problems. Stimulants are renowned for causing people to clench or grind their teeth, which can destroy tooth enamel and even cause cracking. Methamphetamine is well-known for the damage it incurs upon teeth—users often suffer from cavities and discolored or broken teeth. Meth contains numerous toxic and corrosive chemicals that eat away at tooth enamel.

Certain substances, including alcohol and opiates, can cause vomiting. The acid from the vomit eats away at the tooth enamel. A nicotine addiction, most notoriously for those that chew, can cause gum disease and other dental problems.

  • Substance abuse: Individuals that suffer from bulimia may use drugs or alcohol to temper or self-medicate the physical, mental, and emotional stress that results from their eating disorder.
  • Mental health issues, including depression and anxiety: Chronic drug or alcohol use, affects your brain’s neurotransmitters which are responsible for maintaining the mood. The National Institute on Drug Abuse cites that “compared with the general population, people addicted to drugs are roughly twice as likely to suffer from mood and anxiety disorders.” It is important to note, that just as with bulimia, these mental disorders may either precipitate drug or alcohol use or stem from it.
  • Dehydration, which can precipitate more serious medical concerns: Alcohol is dietetic, which means that it encourages your body to produce urine. If a person drinks large quantities of alcohol this can lead to dehydration. For a person that is inebriated, their body may misinterpret the body’s signal of being thirsty as a reason to consume more alcohol, thus stressing the body even further.

An individual that struggles with a drug or alcohol addiction may commonly overlook the basics of their self-care, including drinking water and staying hydrated. They may also make poor nutritional choices and consume things that cause further dehydration, including an excess of salty foods and coffee.

Water is necessary for your kidneys to function properly and paired with the toxic overload of the substance, your kidneys can become overburdened and go into distress as they are unable to process the toxins out of your body. In the worst cases, this could lead to kidney failure.

  • Electrolyte, nutrient, and chemical imbalances: When electrolytes become imbalanced, either falling too low or rising too high, a person is at greater risk for a heart attack and stroke. While a person purging themselves of food does not have the opportunity to fully obtain essential minerals, chemicals, and vitamins from their food, a person that has a substance abuse problem also has an impaired ability to derive these beneficial elements from their food. This is because the alcohol or drug impedes these things from fully absorbing into your body. People that struggle with substance abuse often overlook good dietary and nutrition practices and do not eat enough or consume foods that do not supply them with these necessary things.

Alcohol addiction places a toxic overload on your body’s metabolic systems, specifically affecting the liver and pancreases. When these organs are damaged, fluid and electrolyte levels are compromised.

As a person contends with certain opiate dependence, they might turn to excessive laxative use to ease constipation. Medscape reports that “chronic use of stimulant laxatives can lead to serious medical consequences such as fluid and electrolyte imbalance.” During withdrawal from opiates, a person may encounter intense bouts of nausea, vomiting, or diarrhea, all of which can offset your body’s balance of sodium, potassium, magnesium, and chloride.

  • Pancreatitis: This is characterized by severe inflammation of the pancreas. Chronic alcohol use causes pancreatitis.
  • Low blood pressure: Certain drugs, such as opiates, sleeping pills, and tranquilizers depress the central nervous system and can cause a drastic, and at times dangerous, drop in blood pressure.
  • Esophageal damage: As we mentioned above, numerous drugs can cause vomiting either as a side effect of use or withdrawal. Vomit’s acidic and caustic nature can destroy or inflame the esophagus’ delicate lining and damage may extend from inflammation to more chronic ulcers. Chronic and persistent alcohol use increases the risk of esophageal cancer.
  • Suicide: Just as drug or alcohol use affects the neurotransmitters and regions of the brain that are responsible for mood regulation, it also affects those responsible for supporting judgment and sound decision-making. The National Institutes of Health site PubMed published an article on the correlation between drug and alcohol dependence and suicide. It cited that “over fifty percent of all suicides are associated with alcohol and drug dependence and at least 25% of alcoholics and drug addicts commit suicide.”
  • Irregular or missed periods: Cocaine, opiates, and heavy alcohol use can cause irregular periods. Researchers theorize this is because of their effect on the body’s many systems and hormones that are vastly interconnected during menstruation.

Keep in mind that if you are suffering from both bulimia and substance abuse, the damage and risk to both your physical and mental health increase. The prevalence of the symptoms of bulimia, can at times, obscure those of concurrent substance abuse. When seeking treatment, it is imperative that you inform your medical team of all other conditions. This includes any drug or alcohol use so that you receive the most thorough and directed care possible.

Research Suggests That Bulimia May Be An Addictive Behavior

Research is increasingly illustrating that eating disorders, like drug or alcohol addictions, impact your brain’s chemical makeup. Specifically, they alter the functioning and production of your brain’s neurotransmitters. After a person ceases their bulimic behavior, brain scans show a marked change in neurotransmitter levels, in this case, serotonin.

Psychiatric Times published an article that examined the correlation between addiction and eating disorders and expounded on this theory, stating how the “dopaminergic (DA) reward pathway of the brain” was affected, stating that “in other words, starving, bingeing and exercise all serve as drug delivery devices since they increase circulating levels of -endorphins that are chemically identical to exogenous opiates, and these endorphins are as potentially addictive because of their ability to stimulate DA in the brain’s mesolimbic reward centers.”

Eating disorders and substance abuse often arise in response to stressful situations. Some research suggests that like substance abuse, a person may use bulimia—specifically the binge and purging cycle—as a means to self-medicate comorbid mental health concerns and other issues.

In fact, some people report an alleviation of stress and negative emotions after completing the binge and purge cycle. In addition, some research suggests that those who struggle with bulimia may actually experience a “high” when they purge that could be due to the effect that bulimia has on the serotonin levels within the brain.

Coupled with substance abuse, this fuels and perpetuates a dangerous cycle of self-destruction. These are just a few characteristics that lead some scientists to theorize that bulimia may fall under the classification of addictive behavior.

There are certain factors that stand out as being indicative of a problem with an eating disorder that is also hallmarks of substance abuse or addiction. According to an article written by Carolyn C. Ross M.D., M.P.H. and published by Psychology Today, these include:

  • Obsessive preoccupation, cravings, and rituals surrounding an addictive behavior
  • An escalation in frequency or intensity over time
  • Sacrificing other interests to spend more time on an addictive substance/behavior
  • Inability to stop a destructive behavior despite repeated attempts
  • Loved ones expressing concern about a particular behavior
  • Continued use of a substance/behavior despite negative consequences

The good news is that even though your recovery might in many ways be more complex with two disorders, by understanding the factors that are intertwined with both, you could very well learn skills and mindsets that are critical to conquering each.

Treating Bulimia and Substance Abuse

It is only by treating all co-occurring conditions that you can truly develop and succeed at a recovery plan and achieve greater health, wellness, and sobriety. Many programs exist to treat bulimia and substance abuse separately, though fewer exist with the training and support necessary to treat both at the same time.

Psychology Today explains the risks of treating them separately, stating “what usually happens is that the individual gets help for either an eating disorder or drug addiction, and when that goes into remission the other condition crops up. The patient goes from one treatment facility to another, thinking they’re making progress but ending up stuck in an endless cycle of remission and relapse.”

Because of this, it is very important that you take the time to research your options, ask questions, and compare treatment programs. Both bulimia and substance abuse stem from a wide and varied history that is unique to each person. Taking the time to perform these duties helps ensure that you can find a program that is the best fit for your situation.

Certain comorbid mental health disorders may also be present with those that suffer from both bulimia and substance abuse, two of the most common being depression and borderline personality disorder. In addition to extensive training within bulimia and substance abuse, any program you enter should also be adept at treating any mental health concerns.

One thing that is different and more difficult about treating an addiction verse an eating disorder is a fact that substance abuse recovery, a person seeks to abstain from drugs or alcohol and remove it from their life. On the other hand, someone with an eating disorder cannot remove food from their life. For this reason, the approach needs to be different.

A person needs to learn how to engage food differently by being taught how to change the behaviors, perspectives, and coping mechanisms that surround their mental, emotional, and physical interactions with food.

Both bulimia and addiction should be addressed through therapy, either on an individual basis or in a group setting; cognitive behavioral therapy has shown success in both disorders. Rehabilitation may occur on either an inpatient or outpatient basis, this will be determined by the severity of your situation.

In order to determine this, the health care practitioner that is working with you will likely administer separate evaluations to determine the extent and presence or your eating and substance abuse disorders, along with your perceptions and behaviors that revolve around each. This will occur in two parts, screening, and an assessment.

During the screening, a questionnaire may be administered, either by means of an interview or through self-reporting. This is followed by the assessment during which the administration will further expound on the information obtained through the screening and direct their inquiry to more fully ascertain the extent of the disorder and the appropriate treatment.

Due to bulimia’s effect on serotonin levels, certain selective serotonin-reuptake inhibitor (SSRIs) antidepressants are used within the treatment. Prozac has been shown to markedly alleviate the harmful characteristics of this disorder and achieve success towards helping a person regain control over their eating habits.

Prior to or upon entering into treatment, you need to fully disclose your medical and addiction history. This includes any current medical conditions and any past or current drug use or abuse. Due to the wide and varied side effects and risks associated with each condition, it is crucial that your medical team fully understand any and all health concerns and drug use that you may have.

Remember—there is another similarity between bulimia and addiction—the recovery is a journey and a process, one that takes time and commitment, a recovery that may very well require lifelong maintenance.

Stop The Dangerous Cycle

Bulimia and substance abuse disorders can uproot a person’s health, happiness, and wellbeing, leaving them emotionally, physically, and mentally distraught. If you’re overcome with one or either of these disorders and wants to seek help, look no further than We can help you find the answers and information that can best serve you in making one of the best decisions you’ll ever make—to begin treatment.

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